A regional consensus recommendation on brain atrophy as an outcome measure in multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is a chronic autoimmune disease characterized by inflammatory and neurodegenerative processes leading to irreversible neurological impairment. Brain atrophy occurs early in the course of the disease at a rate greater than the general population. Brain volume loss (BVL) is associated with disability progression and cognitive impairment in patients with MS; hence its value as a potential target in monitoring and treating MS is discussed. METHODS: A group of MS neurologists and neuro-radiologists reviewed the current literature on brain atrophy and discussed the challenges in assessing and implementing brain atrophy measurements in clinical practice. The panel used a voting system to reach a consensus and the votes were counted for the proposed set of questions for cognitive and brain atrophy assessments. RESULTS: The panel of experts was able to identify recent studies, which demonstrated the correlation between BVL and future worsening of disability and cognition. The current evidence revealed that reduction of BVL could be achieved with different disease-modifying therapies (DMTs). BVL provided a better treatment and monitoring strategy when it is combined to the composite measures of "no evidence of disease activity" (NEDA). The panel recommended a set of cognitive assessment tools and MRI methods and software applications that may help in capturing and measuring the underlying MS pathology with high degree of specificity. CONCLUSION: BVL was considered to be a useful measurement to longitudinally assess disease progression and cognitive function in patients with MS. Brain atrophy measurement was recommended to be incorporated into the concept of NEDA. Consequently, a consensus recommendation was reached in anticipation for implementation of the use of cognitive assessment and brain atrophy measurements on a regional level.

Hypothalamic hamartoma presenting with gelastic seizures, generalized convulsions, and ictal psychosis.

We report a case of hypothalamic hamartoma in an adult female who presented with gelastic seizures, generalized convulsions, and ictal aggressive psychotic behavior. Anticonvulsant treatment was ineffective in controlling the epileptic seizures. Surgical excision after accurate imaging diagnosis 3 decades after the onset of symptoms markedly ameliorated her condition. Delayed and erroneous diagnosis had unnecessarily prolonged the suffering of our patient.

Hypothalamic hamartoma presenting with gelastic seizures, generalized convulsions, and ictal psychosis

We report a case of hypothalamic hamartoma in an adult female who presented with gelastic seizures, generalized convulsions, and ictal aggressive psychotic behavior. Anticonvulsant treatment was ineffective in controlling the epileptic seizures. Surgical excision after accurate imaging diagnosis 3 decades after the onset of symptoms markedly ameliorated her condition. Delayed(AU)

Cerebral venous thrombosis. Clinical presentation and outcome in a prospective series from Sudan.

OBJECTIVE: To describe the presentation and outcome of treatment of cerebral venous thrombosis (CVT) in patients from Sudan, an example of a developing country. METHODS: In a prospective study, we described the clinical features, risk factors, and outcome of CVT in patients admitted to the National Center for Neurological Diseases, Khartoum, Sudan, the only specialized neurological hospital in the country, during the period from February 2001-October 2006. Patients were referred from other hospitals in the town or from nearby hospitals in Khartoum state. RESULTS: We recruited only adult and adolescent patients aging >/=15 years. We reviewed 15 patients (12 females and 3 males) with a mean (+/-SD) age of 33.9+/-11.8 years. Headache (n=15), papilledema (n=13), paresis (n=3), and generalized seizures (n=3) were the most common symptoms, and signs encountered. A prothrombotic risk factor was often identified (n=12). At the time of the first visit namely, 12 weeks after discharge, 7 patients (46.7%) attained complete neurological recovery, 4 (26.7%) developed optic atrophy, and 2 (13.3%) died of pulmonary embolism. CONCLUSION: The clinical features and risk factors of CVT in Sudan are not different from elsewhere, but the outcome is less favorable. Places with less privileged health service resources, late presentation or delayed accessibility to appropriate diagnostic tools may negatively influence the final outcome.

Anticardiolipin antibodies in stroke patients in Sudan. Appraisal of their significance in a region of high burden of endemic infections.

OBJECTIVE: To screen and evaluate the significance of anticardiolipin seroprevalence in patients with acute ischemic stroke, in patients with infectious disease, and in healthy subjects resident in Sudan, a tropical country endemic for several infectious diseases. METHODS: We conducted the study in Khartoum Teaching Hospital in Khartoum, Sudan between July 2003 and January 2005. We included 89 stroke cases, 30 infectious disease patients, and 30 asymptomatic healthy subjects. We estimated IgG and IgM anticardiolipin antibody titers in serum samples from all subjects in the 3 study categories at the time of hospital admission. RESULTS: We found a significantly higher prevalence of anticardiolipin antibodies in the stroke and infection groups compared to the healthy subjects. However, there was no significant difference in anticardiolipin seroprevalence between patients with stroke and patients with infectious disease. CONCLUSION: Caution is necessary when interpreting the presence of antiphospholipid antibodies as a stroke risk in patients harboring infection or living in places with high endemicity of infectious diseases.

Parasite diversity in adult patients with cerebral malaria: a hospital-based, case-control study.

Thirty adult patients with cerebral malaria (CM) were recruited for this study. Two clinical groups were used as controls: those with mild malaria (n = 20) and asymptomatic volunteers (n = 20). Thick and thin blood smears were examined for detection of Plasmodium falciparum and estimating infection intensity. A nested polymerase chain reaction (PCR) using allele-specific primers for merozoite surface protein gene was used to determine the parasite diversity of Plasmodium falciparum causing CM. Plasmodium falciparum was detected in blood smears of all malaria patients. No significant difference in parasite count was found between the groups. Thirteen (65%) of the asymptomatic volunteers had a positive PCR for P. falciparum. Multiple alleles were found in 17 (58.6%) patients with CM, but only in 7 (35.6%) with uncomplicated malaria. Multiple alleles were also found in 6 (46.2%) of the 13 PCR-positive asymptomatic individuals. We could not identify a specific strain or strains of P. falciparum that showed a significant association with disease severity. Therefore, we assume that the development of CM in adults residing in endemic areas is more dependent on strain multiplicity rather than on a specific strain or strains of P. falciparum, and that the parasite intensity has no relationship with disease severity. Asymptomatic adults may repeatedly be exposed to low levels of a wide range of different strains during low transmission season and acquire sub-patent parasitemia. This may also confer premunition that renders them relatively resistant to CM.

Guillain-Barré syndrome following acute falciparum malaria.

Plasmodium falciparum malaria is often complicated by involvement of the gastrointestinal, cardiovascular, and nervous systems. The development of Guillain-Barré syndrome in 10 patients who had had acute P. falciparum malaria during its seasonal exacerbation is reported.

Acute stroke type, risk factors, and early outcome in a developing country: a view from Sudan using a hospital-based sample.

This hospital-based prospective study was conducted to determine stroke type, risk factors, and early outcome in patients admitted with acute stroke in both Khartoum and Shaab hospitals located in the capital city of Sudan. Consecutive stroke patients presenting within 48 hours of onset were included in the study. Data were obtained from history taking, physical examination, and investigations. Cranial computed tomography (CT) scanning was performed on 18 patients. The diagnosis of stroke type in patients who did not have CT examination was determined by clinical criteria. Ninety-six patients, 56 males and 40 females, were studied. The peak age group was 61 to 80 years. Stroke caused by infarction was found in 58.3% while stroke caused by hemorrhage was found in 41.6%. Hypertension was the most common associated risk factor, constituting 46.9%. Cardiac disease was found in 16%, diabetes mellitus in 14.6%, syphilis in 4.1%, and previous transient ischemic attack in 2.1%. The overall mortality was higher than in western countries. Risk factors for stroke in Sudan are the same as elsewhere; however, the peak age group is one decade earlier than in developed countries. In developing countries, promoting hypertension and acute stroke health care programs are essential to cutting morbidity and mortality rates.